Provider Demographics
NPI:1225399710
Name:RODRIGUEZ, JACINDA (LPN)
Entity Type:Individual
Prefix:MS
First Name:JACINDA
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 DEHNHOFF AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-2303
Mailing Address - Country:US
Mailing Address - Phone:516-771-6405
Mailing Address - Fax:
Practice Address - Street 1:76 DEHNHOFF AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-2303
Practice Address - Country:US
Practice Address - Phone:516-771-6405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY271324164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse